Ruminations by a non-academic general surgeon from the heart of the rust belt.

Wednesday, October 1, 2008

Needle Stick

Bongi recently had a post about an experience getting stuck by a needle while operating on an HIV positive patient. It reminded me of a time during my residency I had forgotten.

I was a second year resident on the transplant service and it was out of control busy. My program had just added a new liver transplant surgeon who had quadrupled the surgical volume in the 6 months he had been at Rush. Unfortunately, our program still hadn't changed the resident distribution to account for the extra work so there was just a PGY-1, a PGY-2, and a PGY-3 taking care of over thirty patients. We absolutely got killed but it was fun because, as junior residents, we did a lot of operating. Not many second year residents in American surgery programs get to first assist on a liver transplant and put all the stitches in on a portal vein anastomosis.

I was post call and there were seemingly a thousand AV fistula cases to do before I could go home. I'd been up all night during the call doing a kidney transplant. The third year was stuck in a liver case and the intern was running around like a headless chicken trying to take care of the patients in the ICU and on the floors. It was around four o'clock in the afternoon when I introduced myself to the last AV fistula case.

Initially, I thought I'd entered the wrong room. The patient was on an oxygen mask and he was curled like a wounded calf on the bed. He appeared to weigh somewhere between 60 and 67 pounds. He looked at me with these dead black eyes. He wouldn't talk, just nodded his assent to my queries. His skin hung like an ill-fitting rubber mask from his protruding facial bones. He was a skeleton, thinly clad in papery, translucent skin. I reviewed his chart. He was HIV positive. His last CD4 count was less than 50. He was on five different medications. The note from his ID doc indicated that he had a "highly resistant strain" of HIV. And he had renal failure. He needed a fistula.

As a second year resident, I didn't question anything. Somebody had decided he needed a fistula. So be it. I wheeled him back to the OR. Of course now, looking back, the whole scenario is absurd. An AV fistula takes months to mature. You can't even consider using them right away. What were we thinking? This man needed dialysis access? He needed a bed at hospice.

In those days, the attending would scrub in briefly, make sure the anastomosis was lined up properly, and then we were on our own. The case actually went quite well. There was a nice thrill in the venous limb when I released the clamps and I proceeded with the closure. As the attending was leaving, he asked me a couple questions about patients on the floor. I wasn't paying close attention, my eyes off the operative field when I felt a sharp prick on my index finger. Looking down, my heart sank; the creamy white of the glove was rapidly staining red from the inside. I ripped the glove off and blood was pouring from a deep wound. It hurt like hell. I felt it to the bone. I started dumping betadine on it, then wrapped it in gauze. The attending sent me down to employee health.

When you sustain a needle stick injury, you get plugged into the "system". You get your blood drawn. You meet with the nurse practitioner. An incident report is filed. You basically spend three hours in employee health. Then I met with the ID specialist. This was the same guy, coincidentally, who took care of my patient. He shook his head, reading the chart. Of all the people to get stuck by, he said. That night he started me on three different HIV drugs. Nothing beats gagging down three horse pills four times a day. Back at employee health, I met with a counselor. She was very nice and gentle and everything, but she made me feel like I was already infected. I was given literature on "dealing with HIV". I was encouraged to attend local HIV support group meetings. Lots of pamphlets. Thanks, but no thanks, I told her.

Once I finally got home, I was in shock. I hadn't slept in 36 hours and my finger still throbbed and I had fifteen jawbreaker-sized pills to swallow. I felt like my life had suddenly veered into a brick wall. I had just gotten engaged. I was going to be a surgeon. I was living in Chicago. I wanted a family and a nice life and to be a good father to a couple of rugrats. And now everything seemed to be in jeopardy.

In retrospect, my fears were exaggerated. The risk of HIV transmission after getting stuck by a hollow bore needle is 0.3%. I was hurt by a suture needle, which further reduces the chance of transmission. Furthermore, there has never been a documented case of a surgeon acquiring HIV from a needle or scalpel. But at that time, I was a basket case. The rapid HIV test wasn't available then, so I had to wait the full four months to assess for possible seroconversion. Intially, the days crawled by painfully. I couldn't stop thinking about it. About three weeks after the incident I developed a horrible cold. Granted, it was winter in Chicago and everyone was getting it and I hadn't been sleeping or eating well, but I wondered; is this the prodromal HIV flu? I refused to acknowledge the possibility. It was the only way to get through the days.

After I got my blood drawn four months later, I didn't call the lab for the results for two weeks. I figured if it was positive they would have contacted me. But I was also terrified. I didn't want the burden of knowledge. I wasn't ready.

Finally, I got off early one day post call while on trauma. I went to some sleazy bar and gunned down a couple of beers. Courage restored, I went to employee health and requested the results. When they told me it was negative I felt lighter than air. This invisible, oppressive burden I'd been hauling around for months had finally been lifted. I could breathe again. My reprieve had come through. I made a lot of promises to myself that day. How I would be the most dedicated and empathetic surgeon on earth. How I was going to be the best husband to my wife. How I was going to make the most of time, wringing every last drop of utility and meaning and enrichment from my remaining waking days. Philosophy and kindness and charity and all that rigamarole. It would start that afternoon and last the rest of my life.

After a couple weeks, I forgot my vows. It didn't take long. I started getting pissed off again at stupid inconveniences. I wasted time watching sports and surfing the internet. Once again, I was consumed with the minutiae of my narrow, regimented life. The years rolled by and I forgot about the whole episode.

Reading Bongi's post brought it all back. And strangely enough, a small part of me sort of misses that time. There was something powerfully existential and substantive about it all. Rarely do we visit those dark places of the soul where our ultimate weaknesses are exposed. Rarely do we acknowledge our ineluctable mortality. It's too much. It throws us off our fragile equilibrium. There's too much to do in the here and now. But the time will come for all of us. The day of reckoning is unavoidable. Whether it's lump in the breast or a heart attack at age 47 or a sudden stroke or a car that runs a red light. Eventually, there's a needle stick that gets us all. And I think it hurts, initially, no matter how old you are when it happens.

That sucks, especially since they're only testing you so they can let you go when you seroconvert. Or maybe if you're lucky they'll let you do something where theres no blood. A few of my Buds didn't report there own needle sticks back in the 80's just for that reason, going the low buck route of donating blood, and hoping not to here back from the Red Cross.

This was absolutely the best post I've read on your blog. I'm a med student and I assist on abdominal procurements pretty often. My greatest fear is that I get HCV from one of our HCV + donors. Not only would I run the risk of ending up with a Mercedes scar, and a lifetime of immuno suppression, I wouldn't be able to post the titers to start a surgical residency. Dream over. Scary stuff.

That is interesting. I had my first needlestick a few weeks ago, while suturing up an elderly gentleman, also from a suture needle. He was about the lowest risk you could get though so I wasn't concerned (though I probably should have been more concerned as technically he could have had HIV as much as anyone). The tests were fine, but it was a good reminder...

We have all been there. Choking down those pills for a month is unbelievably life altering. Happened during my residency, had to put a triple lumen in an AIDS patient hopped up on coke. I wouldn't let my juniors do it. He wouldn't lay still. My life flashed in front of my eyes and put a few things in perspective on where i was going. Thanks for sharing.

Interesting story, well told. I guess us poor ol' overservicing ID physicians are of some use to you omnipotent surgeons after all!

I manage a few people who have acquired HIV via occupational exposure. Its a tragic scenario, particularly as early access (<8h ideally) to post exposure prophylaxis can prevent transmission in the majority (probably about 70%) of cases.

If you're needle-stuck - seek immediate advice - don't fuck around. I personally don't mind being woken 24/7 for this, and will come in, take you through the whole spiel, and get you on drugs (if indicated) within an hour.

BTW, HIV is now a chronic, manageable illness - even multiresistant HIV can be effectively managed in the majority of cases. If you asked me what disease I would rather have - HIV, type 1 diabetes, bowel cancer, or ischaemic heart disease - I would choose HIV, every day of the week.

Hi Jeff - Our research center at U.Va. (International Healthcare Worker Safety Center) focuses on prevention of needlesticks and occupational exposures to bloodborne pathogens, so I found your post really interesting. We maintain a website (www.healthsystem.virginia.edu/internet/safetycenter) with resources on occupational exposure prevention. I’d love to include a link to this post if that’s OK. I've interviewed occupationally infected HCWs for our publication, Advances in Exposure Prevention. While needlestick injuries from contaminated needles have a statistically low transmission rate (as you say), they are still the most life-threatening occupational risk for HCWs; for those who are infected, they are life-altering. Just a couple of points of clarification: you said that "there has never been a documented case of a surgeon acquiring HIV from a needle or scalpel." Actually, there are at least two documented cases of HIV infection from scalpel injuries (one involving a surgeon, the other a pathologist). With regards to suture needles, there is one documented case of HIV infection (a nurse assisting with a delivery), and one of HCV infection (a surgeon). I myself have interviewed an HCV-infected U.S. surgeon who believes he was infected from a suture needle injury sustained during his residency (he would be categorized as a “possible” case by the CDC). So suture needles are definitely a proven transmission route for both HIV and HCV. My colleague and I wrote an article about infected surgeons and patient safety in which we documented 132 total cases of HIV, HBV, or HCV surgeon-to-patient transmission worldwide. It’s likely that at least some, if not most, of those infected surgeons were occupationally infected, and that at least some acquired their infections from suture needles. Studies have found that surgeons are the least likely to report needlesticks and blood exposures of all HCW groups, so the scarcity of documented infections among surgeons should not lull them into a false sense of security or keep them from reporting. Reporting is critical for many reasons, including follow-up treatment. Another point – while the average risk of HIV transmission following a needlestick is, as you say, 0.3%, that is only an *average.* Factors that increase risk include visible blood on needle, deep injury, and source patient having end-stage AIDS. Our Center’s focus is on prevention, so we encourage surgeons to use alternatives to sharps whenever possible (Marty Makary at Johns Hopkins is doing great work on sharpless surgery), and substitute blunt suture needles for sharp ones when suturing internal tissue (muscle and fascia).

Ok I was feeling better until the last post. I recently pricked my finger with a curved suture needle suturing in a PICC line on an HIV.Hep C patient. I barely expressed blood and washed immediately. I didn't learn that he was infected until 5 days post injury-so I didn't start meds at the advice of the ID. I'm scared shitless. Don't know his counts but he didn't appear to be end stage. Not on HAART. Realistically should I be freaking out? Can't even think .

can someone please help me with some advice. i am a surgical technologist and i was doing my intern and i was stuck by a suture. in i dont know if it was a dirty suture needle or not it was on the mayo stand ready to be passed off i think. anyway i was doubled gloved, but the bad thing is i dinnt follow prcedure at all!after i have got stuck i did not change gloves for about an hour until the case was done and the first layer on my glove was defiently punctured i filled it up with water. i dont know if the paitent is hiv positive or not. 4 months later i have one swollen lymph node in my neck and three under my chin and it's now been 5 months still negative. i just want to get my life back. i am looking for the day when i can breath again. can someone help me please.

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